American Journal of Obstetrics and Gynecology
Elsevier Inc.
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Delivery for respiratory compromise among pregnant women with coronavirus disease 2019
Volume: 223, Issue: 3
DOI 10.1016/j.ajog.2020.05.035
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Table of Contents

Highlights

Notes

McLaren, London, Atallah, McCalla, Haberman, Fisher, Stein, and Minkoff: Delivery for respiratory compromise among pregnant women with coronavirus disease 2019

Objective

Although rapid recourse to delivery after failed cardiopulmonary resuscitation has been shown to improve outcomes of pregnant patients experiencing cardiac arrest,1, 2 it is not known whether delivery improves or compromises the outcome of patients with coronavirus disease 2019 (COVID-19) experiencing respiratory failure.3, 4 This study aimed to evaluate the safety and utility of delivery of pregnant women with COVID-19 needing respiratory support.

Study Design

This is a retrospective observational study of pregnant women diagnosed with COVID-19 via polymerase chain reaction who developed severe disease (defined per previous publications3). A subset of these cases was previously presented but without details on the effect of delivery on the disease.5 The study was exempted by the institutional review board.

Results

Of 125 confirmed cases of COVID-19, 12 (9.6%) had severe disease (Table ). Among the 12 patients, the condition of 3 patients improved after receiving transient respiratory support in the hospital, and they were discharged home (1 subsequently returned in preterm labor and gave birth by cesarean delivery 2 weeks later). Of the remaining 9 patients who continued to need respiratory support, 7 (77.8%) had iatrogenic preterm deliveries (6 by cesarean delivery) for maternal respiratory distress (needing increasing levels of respiratory support without improved oxygen saturation), 1 had an early term delivery because of premature rupture of membranes, and 1, at 30 weeks’ gestation, was admitted to the intensive care unit with high-flow nasal cannula for 3 weeks.

Table
Characteristics and outcomes of pregnant women with severe COVID-19
Patient number123456789101112
Age (y)443334283732342532243029
BMI (kg/m2)28.430.336.025.929.329.330.832.541.031.042.029.4
Medical historyNoneNonePregestational diabetes, hepatitis BNoneGestational diabetes A2NoneGestational diabetes A1NoneChronic hypertensionNoneNoneNone
Gestational age at initial symptom294334353310285315372330260346260253
Mode of deliveryCesareanCesareanCesareanCesareanCesareanCesareanVaginalCesareanVaginal
IndicationMaternal respiratory distressMaternal respiratory distressMaternal respiratory distressMaternal respiratory distressMonochorionic diamniotic twinsMaternal respiratory distressEarly term PROMMaternal respiratory distressMaternal respiratory distress
Gestational age at delivery314353362324314316372344351
Respiratory supportNonrebreatherSimple nasal cannulaMechanical ventilationNonrebreatherSimple nasal cannulaSimple nasal cannulaSimple nasal cannulaSimple nasal cannulaSimple nasal cannulaSimple nasal cannulaHigh-flow nasal cannulaSimple nasal cannula
ICUNoNoYesNoNoNoNoNoNoNoYesNo
LOS (d)94268773938X5
LOS after delivery (d)7426544385
BMI, body mass index; COVID-19, coronavirus disease 2019; ICU, intensive care unit; LOS, length of hospital stay; PROM, premature rupture of membranes; X, currently admitted for 15 days as of May 1, 2020.
Mclaren. Delivery for respiratory compromise among pregnant women with COVID-19. Am J Obstet Gynecol 2020.

Of the 8 patients delivering with maternal respiratory distress, 7 did not require intubation, and 1 was intubated for emergent cesarean delivery and remained on a ventilator for 19 days. Among the nonintubated, 4 had an improvement in oxygenation within 2 hours after delivery, 2 required less respiratory support, and 2 were taken completely off respiratory support. None of the other 3 patients required an increased level of respiratory support, and they were off of all support between 4 and 7 days after delivery.

Conclusion

Delivery did not worsen the respiratory status of women with persistent oxygen desaturation and the need for increasing respiratory support. Among women not needing a ventilator, the return to normal respiratory status after delivery occurred within hours to days. However, the 1 patient who was intubated intraoperatively took longer to recover. It is possible that delivery may be less salutary when damage to the lungs is sufficient to warrant intubation. This series suggests that maternal respiratory distress should not be a contraindication to delivery.

As noted in a recent Society for Maternal-Fetal Medicine and Society for Obstetric Anesthesia and Perinatology guideline, it is not known whether uterine decompression improves respiratory status; we are unable to shed light on that issue.4 Although we saw no harm, we cannot be certain that delivery per se caused the improvement we observed or whether a similar outcome could have been achieved with ongoing respiratory support (although 1 of 3 patients managed conservatively remained on respiratory support for 3 weeks). In summary, although more data on the effects of delivery are needed, we have shown in a small series that women with COVID-19 requiring respiratory support fared well when they underwent delivery.

References

1 

    Society for Maternal-Fetal MedicinePacheco L.D., Saade G., Hankins G.D., Clark S.L.. Amniotic fluid embolism: diagnosis and management. Am J Obstet Gynecol 215: 2016. , pp.B16-B24

2 

    Jeejeebhoy F.M., Zelop C.M., Lipman S.. Cardiac arrest in pregnancy: a scientific statement from the American Heart Association. Circulation 132: 2015. , pp.1747-1773

3 

    Society for Maternal-Fetal Medicine. Management considerations for pregnant patients with COVID-19. https://s3.amazonaws.com/cdn.smfm.org/media/2334/SMFM_COVID_Management_of_COVID_pos_preg_patients_4-29-20_final.pdf,

4 

    Society for Maternal-Fetal Medicine, Society for Obstetric and Anesthesia and Perinatology. Labor and delivery COVID-19 considerations. https://s3.amazonaws.com/cdn.smfm.org/media/2327/SMFM-SOAP_COVID_LD_Considerations_-_revision_4-14-20_-_changes_highlighted.pdf,

5 

    London V., McLaren R., Atallah F.. The relationship between status at presentation and outcomes among pregnant women with COVID-19. Am J Perinatol 2020.

Notes

The authors report no conflict of interest.
This communication has been published in the middle of the COVID-19 pandemic and is available via expedited publication to assist patients and healthcare providers.
https://www.researchpad.co/tools/openurl?pubtype=article&doi=10.1016/j.ajog.2020.05.035&title=Delivery for respiratory compromise among pregnant women with coronavirus disease 2019&author=Rodney A. McLaren,Viktoriya London,Fouad Atallah,Sandra McCalla,Shoshana Haberman,Nelli Fisher,Janet L. Stein,Howard L. Minkoff,&keyword=&subject=Research Letter,